Implementing the PCMH: The practice experience

Richard J. Baron, MD, FACPCEO, Greenhouse Internists, PC

Chair, American Board of Internal Medicine

PCPCC Stakeholders’ Working MeetingJuly 16, 2008Washington, DC

Agenda Item: II

Patient Centered Medical Home = Driving/managing change FFS “guiding principle” of practice organization

Internal productivity/compensation metrics Justification for resource decisions

“New activities” represent real “work” Longer days? Less FFS revenue? Both?

We are really starting a “new business” Space, staff, technology, organization

Radical Re-Design: Examples of “new activities” HIT and its management

Creation of office policies and procedures

(Re)-Training of (new) staff

Protocol development and implementation

Non-visit based care E-mail, pro-active chronic disease management, population

based care

New Skills are Required Expert diagnostician and clinician Patient advocate Effective communicator Team leader and an effective teammate Systems manager Effective user of health information technology and

health data Effective change agent Practitioner accountable for efficient, accessible

care

In Summary Physicians are not well trained or well prepared to

create a PCMH

As Med-PAC has said, resources- both short and long term- will be needed to make this work

Will need creative support of primary care training and practice to make this work

Framing Principles Think in terms of overall practice costs for doing this

Avoid the “4 foot rope for a 10 foot hole” Best to think as “percentage of practice gross”

Require – and fund- EHRs Need them to activate teams/offload docs Need them to manage and measure Need them for enhanced communication

Pro rata funding model (SEPA Pilot, almost) a good option for multi-payer

What does it cost to make it happen? Allocation of 10% active time

per physician on “new activities” No FFS revenue? That’s

10% of practice gross revenue, or around $42.5K per doc

Physician Time

$42,500

$0

$10,000

$20,000

$30,000

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$50,000

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Annual Cost

What does it cost to make it happen? Allocation of 10% active time

per physician on “new activities” No FFS revenue? That’s

10% of practice gross revenue, or around $42.5K per doc

Add new staff Health Educator $57K plus

benefits plus indirects One more MA, one more

Front Desk to be “activated team”

Maybe part of a Social Worker, maybe an NP/PA

Physician Time

$42,500

Staff $42,500

$0

$10,000

$20,000

$30,000

$40,000

$50,000

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Annual Cost

What does it cost to make it happen? Technology related

EHR acquisition and training: $70-80K/doc

Ongoing support: $12-15K/doc annually

Data analytics: $25-50K/year

Physician Time

$42,500

Staff $42,500

Technology$26,200

$0

$10,000

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$30,000

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Annual Cost

What does it cost to make it happen? Technology related

EHR acquisition and training: $70-80K/doc

Ongoing support: $12-15K/doc annually

Data analytics: $25-50K/year

Miscellaneous Space Materials

Physician Time

$42,500

Staff $42,500

Technology$26,200

Misc. $5,000

$0

$10,000

$20,000

$30,000

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Annual Cost

What does it cost to make it happen?

Total: Around $117,000 per FTE physician, or 27.5% premium over usual gross

And this does NOT factor in any actual salary increase to physicians; will ALSO need a strategy to “revitalize” primary care . . .

What is Greenhouse doing? Hired a health educator Hiring more Front Desk/MA folks Not hiring an NP/PA Arguing about need for new space Interacting more with our technology Did our own CG-CAHPS survey Working toward developing more systematic non-visit

based care Hoping to pay docs more, “recoup” EHR investment

What is ABIM Doing? Defining a new job description for generalists and

related competencies, e.g. team skills, patient advocacy (CCIM)

Research (CC PIM) to understand relationship between clinical performance, patient experience and the system – with a focus on the “human factors”

Seeking partners to field CC PIM and CCIM assessments as a tool for physicians to diagnose practice strengths & weaknesses

Making the case that MOC should be part of the PCMH

To sum up PCMH is not just a variation on “traditional” primary care:

Need new skills from the physicians Need new capacities in the practice Need new resources to support those capacities and reward

those physicians

The presence of all 3 is the surest way to see an ROI from these projects